Basic Information
| Provider Information | |||||||||
| NPI: | 1235543463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNESBORO HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAYNESBORO HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 JV MANGUBAT DR | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317223641 | ||||||||
| FaxNumber: | 9317227215 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 JV MANGUBAT DR | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317223641 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2014 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 4235846755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000278 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440620 | 05 | TN | MEDICAID | 0445518 | 05 | TN | MEDICAID |